The importance of viral load in the severity of acute bronchiolitis in hospitalized infants

OBJECTIVE: The relationship between viral load and the clinical evolution of bronchiolitis is controversial. Therefore, we aimed to analyze viral loads in infants hospitalized for bronchiolitis. METHODS: We tested for the presence of human respiratory syncytial virus (HRSV) or human rhinovirus (HRV) using quantitative molecular tests of nasopharyngeal secretions and recorded severity outcomes. RESULTS: We included 70 infants [49 (70%) HRSV, 9 (13%) HRV and 12 (17%) HRSV+HRV]. There were no differences among the groups according to the outcomes analyzed individually. Clinical scores showed greater severity in the isolated HRSV infection group. A higher isolated HRSV viral load was associated with more prolonged ventilatory support, oxygen therapy, and hospitalization days, even after adjustment for the age and period of nasopharyngeal secretion collection. In the co-infection groups, there was a longer duration of oxygen therapy when the HRSV viral load was predominant. Isolated HRV infection and co-infection with a predominance of HRV were not associated with severity. CONCLUSION: Higher HRSV viral load in isolated infections and the predominance of HRSV in co-infections, independent of viral load, were associated with greater severity. These results contribute to the development of therapeutic and prophylactic approaches and a greater understanding of the pathophysiology of bronchiolitis.

Quality of life of adolescents with type 1 diabetes

INTRODUCTION: Diabetes mellitus is a highly prevalent chronic disease. Type 1 diabetes mellitus usually develops during infancy and adolescence and may affect the quality of life of adolescents. OBJECTIVE: To evaluate the quality of life of adolescents with type 1 diabetes mellitus in a metropolitan region of western central Brazil. METHODS: Adolescents aged 10-19 years who had been diagnosed with type 1 diabetes mellitus at least 1 year previously were included. Patients with verbal communication difficulties, severe disease, and symptomatic hypo- or hyperglycemic crisis as well as those without an adult companion and who were <18 years of age were excluded. The self-administered Diabetes Quality of Life for Youths instrument was applied. RESULTS: Among 96 adolescents (57% females; 47% white, and 53% nonwhite), 81% had an HbA1c level of >7%. In general, the adolescents consistently reported having a good quality of life. The median scores for the domains of the instrument were as follows: “satisfaction”: 35; “impact”: 51; and “worries“: 26. The total score for all domains was 112. Bivariate analysis showed significant associations among a lower family income, public health assistance, and insulin type in the “satisfaction” domain; and a lower family income, public health assistance, public school attendance, and a low parental education level in the “worries“ domain and for the total score. A longer time since diagnosis was associated with a lower total score. Multivariable analysis confirmed the association of a worse quality of life with public health assistance, time since diagnosis, and sedentary lifestyle in the “satisfaction” domain; female gender in the “worries” domain; and public health assistance for the total score. CONCLUSIONS: Overall, the adolescents evaluated in this study viewed their quality of life as good. Specific factors that ...

Infecções por vírus respiratórios em lactentes com suspeita clínica de coqueluche / Respiratory viral infections in infants with clinically suspected pertussis

OBJETIVO: avaliar a frequência das infecções por vírus respiratórios em lactentes hospitalizados com suspeita clínica de coqueluche e analisar suas características admissionais e evolutivas. MÉODOS: foi realizado um estudo de coorte histórica, em um serviço sentinela para coqueluche, no qual a pesquisa de vírus respiratórios também foi rotineira para os lactentes hospitalizados com problemas respiratórios. Foram incluídos todos os lactentes submetidos à notificação compulsória de suspeita de coqueluche. Foram realizadas pesquisas para Bordetela pertussis - BP (PCR/cultura) e vírus respiratórios - VR (imunofluorescência). Foram excluídos os pacientes que haviam recebido macrolídeos previamente à internação. Os dados clínicos foram obtidos dos prontuários. RESULTADOS: dentre os 67 pacientes analisados, a pesquisa para BP foi positiva em 44% e para VR em 26%. Não houve identificação etiológica em 35% e em 5% houve codetecção de VR e BP. Todos os pacientes apresentaram características demográficas semelhantes. A presença de tosse seguida de guincho inspiratório ou cianose foi um forte preditor de coqueluche, assim como, leucocitose e linfocitose evidentes. Coriza e dispneia foram mais frequentes nas infecções virais. Houve suspensão do uso de macrolídeos em 40% dos pacientes com pesquisa positiva para VR e negativa para BP. CONCLUSÃO: os resultados sugerem que lactentes hospitalizados com suspeita de coqueluche podem apresentar infecção viral e a pesquisa etiológica pode possibilitar a redução do uso de macrolídeos em alguns casos. No entanto, salienta-se que o diagnóstico etiológico de infecção por vírus respiratórios, por si só, não exclui a possibilidade de infecção por Bordetella pertussis.

OBJECTIVE: to evaluate the frequency of respiratory viral infections in hospitalized infants with clinical suspicion of pertussis, and to analyze their characteristics at hospital admission and clinical outcomes. METHODS: a historical cohort study was performed in a reference service for pertussis, in which the research of respiratory viruses was also a routine for infants hospitalized with respiratory problems. All infants reported as suspected cases of pertussis were included. Tests for Bordetella pertussis (BP) (polymerase chain reaction/culture) and for respiratory viruses (RVs) (immunofluorescence) were performed. Patients who received macrolides before hospitalization were excluded. Clinical data were obtained from medical records. RESULTS: among the 67 patients studied, BP tests were positive in 44%, and 26% were positive for RV. There was no etiological identification in 35%, and RV combined with BP was identified in 5%. All patients had similar demographic characteristics. Cough followed by inspiratory stridor or cyanosis was a strong predictor of pertussis, as well as prominent leukocytosis and lymphocytosis. Rhinorrhea and dyspnea were more frequent in viral infections. Macrolides were discontinued in 40% of patients who tested positive for RV and negative for BP. CONCLUSION: the results suggest that viral infection can be present in hospitalized infants with clinical suspicion of pertussis, and etiological tests may enable a reduction in the use of macrolides in some cases. However, the etiological diagnosis of respiratory virus infection, by itself, does not exclude the possibility of infection with BP.

Hipotireoidismo congênito: recomendações do Departamento de Tireoide da Sociedade Brasileira de Endocrinologia e Metabologia / Congenital hypothyroidism: recommendations of the Thyroid Department of the Brazilian Society of Endocrinology and Metabolism

O hipotireoidismo congênito (HC) é o distúrbio endócrino congênito mais frequente, com incidência variando de 1:2.000 a 1:4.000 crianças nascidas vivas e uma das principais causas de retardo mental que pode ser prevenida. Os Programas de Triagem Neonatal para a doença permitem a identificação precoce dos afetados e seu tratamento de modo a evitar as complicações da falta do hormônio. A maioria dos casos de hipotireoidismo congênito é decorrente de disgenesias tireoidianas (85%), entre elas a ectopia, hipoplasia ou agenesia tireoidianas, e os demais resultam de defeitos de síntese hormonal. As crianças afetadas (> 95%) geralmente não apresentam sintomas sugestivos da doença ao nascimento. Os sintomas e sinais mais comuns são: icterícia neonatal prolongada, choro rouco, letargia, movimentos lentos, constipação, macroglossia, hérnia umbilical, fontanelas amplas, hipotonia e pele seca. Várias estratégias são utilizadas para a triagem do HC. No Brasil, esta é obrigatória por lei e geralmente é feita com a dosagem de TSH em sangue seco coletado do calcanhar. A idade recomendada para sua realização é após as 48 horas de vida até o quarto dia. A confirmação diagnóstica é obrigatória com as dosagens de TSH e T4 livre ou T4 total.

Congenital hypothyroidism (CH) is the most common congenital endocrine disorder, with an incidence of 1:2,000 to 1:4,000 live births and it is a leading preventable mental retardation. Neonatal Screening Programs allow early identification of the disease and the adequate treatment of affected children can avoid the complications related to deprivation of the hormone. Most cases of primary congenital hypothyroidism (85%) are due to thyroid dysgenesis (ectopia, hypoplasia or agenesis) while the remaining result from defects in hormone synthesis. Affected children (> 95%) usually have no symptoms suggesting the disease at birth. The most frequent symptoms and signs are prolonged neonatal jaundice, hoarse cry, lethargy, slow movements, constipation, macroglossia, umbilical hernia, large fontanelle, hypotonia and dry skin. Around the world, various strategies are used for the screening of the CH. In Brazil, screening for CH is mandatory by law and usually done by serum TSH in dried blood collected from the heel. The recommended age for performing this test is after 48 hours of life until the 4th day. Diagnostic confirmation is required dosing TSH and free T4 or total T4 in serum.

Etiological diagnosis reduces the use of antibiotics in infants with bronchiolitis

OBJECTIVE: Acute bronchiolitis is a leading cause of infant hospitalization and is most commonly caused by respiratory syncytial virus. Etiological tests are not required for its diagnosis, but the influence of viral screening on the therapeutic approach for acute bronchiolitis remains unclear. METHODS: A historical cohort was performed to assess the impact of viral screening on drug prescriptions. The study included infants up to one year of age who were hospitalized for bronchiolitis. Virus screening was performed using immunofluorescence assays in nasopharyngeal aspirates. The clinical data were obtained from the patients' medical records. Therapeutic changes were considered to be associated with viral screening when made within 24 hours of the release of the results. RESULTS: The frequency of prescriptions for beta agonists, corticosteroids and antibiotics was high at the time of admission and was similar among the 230 patients. The diagnosis of pneumonia and otitis was associated with the introduction of antibiotics but did not influence antibiotics maintenance after the results of the virus screening were obtained. Changes in the prescriptions were more frequent for the respiratory syncytial virus patients compared to patients who had negative viral screening results (p =0.004), especially the discontinuation of antibiotics (p<0.001). The identification of respiratory syncytial virus was associated with the suspension of antibiotics (p= 0.003), even after adjusting for confounding variables (p = 0.004); however, it did not influence the suspension of beta-agonists or corticosteroids. CONCLUSION: The identification of respiratory syncytial virus in infants with bronchiolitis was independently associated with the discontinuation of antibiotics during hospitalization.

Lower respiratory tract infection caused by respiratory syncytial virus in infants: the role played by specific antibodies

INTRODUCTION: Respiratory syncytial virus (RSV) is a major etiological agent of lower respiratory tract infection in infants. Genotypes of this virus and the role of the infants' serum antibodies have yet to be fully clarified. This knowledge is important for the development of effective therapeutic and prophylactic measures. OBJECTIVES: To evaluate the types and genotypes of RSV causing respiratory tract infection in infants, to analyze the association of subtype-specific serum antibodies with the occurrence of infection and to evaluate the presence of subtype-specific antibodies in the infants' mothers and their association with the profile of the childrens' serum antibodies. METHODS: This was a prospective study on infants hospitalized with respiratory infection. Nasopharyngeal secretions were collected for viral investigation using indirect immunofluorescence and viral culture and blood was collected to test for antibodies using the Luminex Multiplex system. RESULTS: 192 infants were evaluated, with 60.9 percent having RSV (73.5 percent- A and 20.5 percent B). Six genotypes of the virus were identified: A5, A2, B3, B5, A7 and B4. The seroprevalence of the subtype-specific serum antibodies was high. The presence and levels of subtype-specific antibodies were similar, irrespective of the presence of infection or the viral type or genotype. The mothers' antibody profiles were similar to their infants'. CONCLUSIONS: Although the prevalence of subtype-specific antibodies was elevated, these antibodies did not provide protection independently of virus type/genotype. The similarity in the profiles of subtype-specific antibodies presented by the mothers and their children was consistent with transplacental passage.

INTRODUÇÃO: O vírus sincicial respiratório é um dos principais agentes etiológicos das infecções do aparelho respiratório inferior em lactentes. Os genótipos deste vírus e o papel dos anticorpos séricos ainda não estão esclarecidos. Este conhecimento é importante para o desenvolvimento de medidas terapêuticas e profiláticas. OBJETIVOS: Avaliar: os tipos e genótipos do vírus sincicial que causam infecção respiratória em lactentes e a associação dos anticorpos séricos subtipo-específicos com a ocorrência de infecção; a presença de anticorpos subtipo-específicos nas mães e sua associação com o perfil de anticorpos da criança. MÉTODOS: Estudo prospectivo incluindo lactentes hospitalizados com infecção respiratória. Foi coletada secreção de nasofaringe para investigação viral usando imunofluorescência indireta e cultivo viral. Foi coletado sangue para pesquisa de anticorpos usando o sistema Luminex Multiplex. RESULTADOS: Avaliados 192 lactentes: 60,9 por cento com vírus sincicial (73,5 por cento - A e 20,5 por cento - B). Seis genótipos de vírus sincicial respiratório foram identificados: A5,A2,B3,B5,A7 e B4. A soroprevalência dos anticorpos subtipos-específicos foi alta. A presença e o nível de anticorpos subtipos-específicos foram semelhantes, independentemente da presença de infecção, tipo e genótipo do vírus. As mães e as crianças apresentaram perfis semelhantes de anticorpos. CONCLUSÕES: A prevalência dos anticorpos subtipos-específicos foi elevada mas estes anticorpos não conferiram proteção, independentemente do tipo/genótipo do vírus. A semelhança dos perfis de anticorpos das mães e das crianças foi compatível com transmissão transplacentária.

Clinical patterns and seasonal trends in respiratory syncytial virus hospitalizations in Säo Paulo, Brazil

The respiratory viruses are recognized as the most frequent lower respiratory tract pathogens for infants and young children in developed countries but less is known for developing populations....

Hemossiderose pulmonar idiopática tratada com ciclofosfamida e prednisona / Idiopathic primary pulmonary hemosiderosis: treatment with cyclophosphamide and prednisone

Os autores descrevem o caso de uma criança que teve o diagnóstico de hemossiderose pulmonar idiopática firmado aos 5 anos de idade e que encontra-se em evoluçäo clínica favorável aos 10 anos. O curso da doença foi o princípio tormentoso, visto que näo respondia à utilizaçäo de prednisona e cloroquina. Porém, com a introduçäo de ciclofosfamida, utilizada conjuntamente com a prednisona, o caso entrou em remissäo clínica e radiológica. O paciente está em seguimento ambulatorial sem qualquer medicaçäo há um ano, e nesse período apresentou somente um pequeno episódio de hemoptise. Os autores objetivam, com a relato desse caso, ressaltar a perfil clínico e laboratorial da hemossiderose pulmonar idiopática. Em particular, é destacada a possível utilizaçäo terapêutica de ciclofosfamida e prednisona para alguns casos selecionados da doença.

Febre no lactente jovem atendido em Serviço de Emergência: Aspectos diagnósticos e terapêuticos / Management of febrile infants younger than 2 months of age at the Emergency Care Unit: Diagnosis aspects and therapeutics

Os autores avaliaram 82 lactentes jovens febris, em estudo prospectivo, atendidos no Serviço de Emergência do Hospital Universitário da USP. As crianças foram internadas por 24 horas para esclarecimento causal, exploraçäo laboratorial e início de terapêutica. Foram diagnosticadas 18 infecçöes bacterianas potencialmente graves(21,9 por cento). Patologias significativas foram reconhecidas em 40 lactentes(48,8 por cento). Todos os pacientes foram seguidos até o término do episódio febril, 20 casos ficaram internados, e 62 foram acompanhados ambulatorialmente. Houve utilizaçäo de antimicrobianos em 38 crianças(46,3 por cento). A evoluçäo foi satisfatória em todos os pacientes. Os autores constataram no grupo estudado que os pequenos lactentes febris apresentaram patologias potencialmente graves, que necessitam observaçäo estrita, exploraçäo laboratorial e frequentemente antibioticoterapia. O período de observaçäo no Serviço de Emergência foi importante para realizar a investigaçäo diagnóstica dos casos, avaliar a repercussäo das patologias sobre o lactente, indicar a utilizaçäo de antibioticoterapia e a eventual necessidade de internaçäo.